Provider Demographics
NPI:1164988663
Name:LUSTIG, EDIE
Entity Type:Individual
Prefix:
First Name:EDIE
Middle Name:
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1650
Mailing Address - Country:US
Mailing Address - Phone:208-507-2160
Mailing Address - Fax:
Practice Address - Street 1:711 N STATE ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1650
Practice Address - Country:US
Practice Address - Phone:208-507-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDWA116016B347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle